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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197604143
Report Date:
03/17/2025
Date Signed:
03/17/2025 04:25:27 PM
Document Has Been Signed on
03/17/2025 04:25 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
HEADWAY HOUSE, INC.
FACILITY NUMBER:
197604143
ADMINISTRATOR/
DIRECTOR:
LENA REINHOLDS
FACILITY TYPE:
735
ADDRESS:
8500 SHIRLEY AVENUE
TELEPHONE:
(818) 772-2266
CITY:
NORTHRIDGE
STATE:
CA
ZIP CODE:
91324
CAPACITY:
6
CENSUS:
3
DATE:
03/17/2025
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:
Nicolette Taylor- Administrator
TIME VISIT/
INSPECTION COMPLETED:
04:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with the new Administrator, Nicolette Taylor, and explained the reason for the visit. LPA conducted a record review, and it was revealed that the Administrator was hired last year. However, the Licensee didn't notify CCL within 30 days of a change of administrator. The administrator stated that documents would be sent to the LPA promptly. LPA also observed that the Administrator was not associated with the facility.
At approximately 11:20 a.m., with the assistance of the Administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke detectors were tested. However, the carbon monoxide detectors were not operational. The administrator said that they bought new carbon monoxide detectors, and they will need to be installed today. The fire extinguisher is located in the living area. The charge date is August 13, 2024.
Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked cabinet under the kitchen sink. Bedrooms: The Facility has four (4) Bedrooms. Three (3) bedrooms are designated for clients' use. Two (2) bedrooms are designated for private use, and one (1) room is shared. One (1) bedroom designated for staff. All three bedrooms, in use by clients, were properly furnished with appropriate bedding and linens with sufficient lighting.
Bathrooms: There are two (2) bathrooms designated for clients' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 111.9 and 112.4 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection.
Common Areas: These included the living room and dining area. The common areas were properly furnished. Properly labeled medications were locked in one of the dining cabinets.
(Continue on 809C)
SUPERVISORS NAME
:
Eva Miller
LICENSING EVALUATOR NAME
:
Mariana Agban
LICENSING EVALUATOR SIGNATURE
:
DATE:
03/17/2025
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
HEADWAY HOUSE, INC.
FACILITY NUMBER:
197604143
VISIT DATE:
03/17/2025
NARRATIVE
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Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The outdoor area was free of hazards. Laundry Room/ Garage: LPA observed the laundry room located in the garage. The Garage is attached to the facility and is currently being used for extra storage, an extra refrigerator, and a freezer. There were no chemicals/hazardous items located in the garage.
Resident Files: LPA conducted a file review of resident records to ensure compliance with licensing forms. LPA observed that S1, S2, and S3 are missing physician reports. In addition, clients admission agreements do not have admission dates of the clients. The administrator stated that she would update the records promptly.
Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. LPA observed that the administrator file is missing forms LIC 503 and LIC 508. LPA also observed Staff#3 (S3) is also missing LIC 503.
Medications: Medication and Medication Records were reviewed for proper documentation. LPA observed incomplete medication records for Client#2.
Cash Resources: Facility doesn't have records of Client Safeguarded cash resources (LIC 405) for C3. Temperature: The facility maintains a comfortable temperature of 78 degrees Fahrenheit.
Exit interview conducted, citations and immediate civil penalty issued, copy of this report signed and delivered.
SUPERVISORS NAME
:
Eva Miller
LICENSING EVALUATOR NAME
:
Mariana Agban
LICENSING EVALUATOR SIGNATURE
:
DATE:
03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/17/2025
LIC809
(FAS) - (06/04)
Page:
2
of
8
Document Has Been Signed on
03/17/2025 04:25 PM
- It Cannot Be Edited
Created By:
Mariana Agban
On
03/17/2025
at
03:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
HEADWAY HOUSE, INC.
FACILITY NUMBER:
197604143
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/17/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(e)(1)(A)
Safeguards for Cash Resources.....(e) Cash resources, personal property, and valuables of clients shall be separate and intact, and shall not be commingled with facility funds or petty cash.(1) Records of clients' cash resources..... a current ledger accounting........(A) Receipts for cash provided to any client from his/her account(s).....amount and date received, as follows: This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. There was no records of cash funds for Client#3 (C3) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/25/2025
Plan of Correction
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Administrator agreed to complete the LIC 405 form and email it to LPA by the POC date.
Type B
Section Cited
CCR
85061(b)(1)(2)(3)
The licensee shall notify the licensing agency, in writing, within 30 days of a change of administrator Such notification shall include the following:(1) Name, and residence and mailing addresses of the new administrator.(2) Date he/she assumed his/her position.(3) Description of his/her background and qualifications, including documentation of required education and certification. This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. The Licensee failed to notify CCL regarding the change of Administrator within 30 days which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/25/2025
Plan of Correction
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Administrator will provide all the required document to change the adminisrator name in the system by the POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Eva Miller
LICENSING EVALUATOR NAME:
Mariana Agban
LICENSING EVALUATOR SIGNATURE:
DATE:
03/17/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/17/2025
LIC809
(FAS) - (06/04)
Page:
3
of
8
Document Has Been Signed on
03/17/2025 04:25 PM
- It Cannot Be Edited
Created By:
Mariana Agban
On
03/17/2025
at
03:21 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
HEADWAY HOUSE, INC.
FACILITY NUMBER:
197604143
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/17/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... in a licensed facility: (2)Request a transfer of a criminal record clearance as specified in Section 87355(c)...
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. Licensee failed to associate S1 to the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
03/17/2025
Plan of Correction
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4
Licensee will associate Administrator immediately. An immediate $500 civil penalty is being assesd today.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Eva Miller
LICENSING EVALUATOR NAME:
Mariana Agban
LICENSING EVALUATOR SIGNATURE:
DATE:
03/17/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/17/2025
LIC809
(FAS) - (06/04)
Page:
4
of
8
Document Has Been Signed on
03/17/2025 04:25 PM
- It Cannot Be Edited
Created By:
Mariana Agban
On
03/17/2025
at
03:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
HEADWAY HOUSE, INC.
FACILITY NUMBER:
197604143
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/17/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation the licensee did not comply with the section cited above. LPA observed Carbon Monoxide is not operational which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/19/2025
Plan of Correction
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Administrator will install the new carbon monoxide and will sent proof by the POC date.
Type B
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on observation, the licensee did not comply with the section cited above. LPA observed on Bathroom 1 that the toiled seat is old and has scratches which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/19/2025
Plan of Correction
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Administrator will buy a new toilet seat and will sent proof of purchase and installation by the POC date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Eva Miller
LICENSING EVALUATOR NAME:
Mariana Agban
LICENSING EVALUATOR SIGNATURE:
DATE:
03/17/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/17/2025
LIC809
(FAS) - (06/04)
Page:
5
of
8
Document Has Been Signed on
03/17/2025 04:25 PM
- It Cannot Be Edited
Created By:
Mariana Agban
On
03/17/2025
at
03:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
HEADWAY HOUSE, INC.
FACILITY NUMBER:
197604143
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/17/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above. LPA observed that Administrator file is missing forms LIC 503 and 508. Also S3 is missing form LIC 503 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/25/2025
Plan of Correction
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2
3
4
Administrator will provide copies of the above forms by the POC date
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. LPA observed that Admission Agreement doesn't have the admission date for all 3 clients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/25/2025
Plan of Correction
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2
3
4
Administrator will provide update admission agreement with admission date for the 3 clients by the POC date
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Eva Miller
LICENSING EVALUATOR NAME:
Mariana Agban
LICENSING EVALUATOR SIGNATURE:
DATE:
03/17/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/17/2025
LIC809
(FAS) - (06/04)
Page:
6
of
8
Document Has Been Signed on
03/17/2025 04:25 PM
- It Cannot Be Edited
Created By:
Mariana Agban
On
03/17/2025
at
03:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
HEADWAY HOUSE, INC.
FACILITY NUMBER:
197604143
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/17/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above. All three clients are missing medical assesment which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/01/2025
Plan of Correction
1
2
3
4
Administrator will provide three medical assessment for all 3 clients by the POC date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Eva Miller
LICENSING EVALUATOR NAME:
Mariana Agban
LICENSING EVALUATOR SIGNATURE:
DATE:
03/17/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/17/2025
LIC809
(FAS) - (06/04)
Page:
7
of
8
Document Has Been Signed on
03/17/2025 04:25 PM
- It Cannot Be Edited
Created By:
Mariana Agban
On
03/17/2025
at
03:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
21731 VENTURA BLVD., STE. 250
WOODLAND HILLS
,
CA
91364
FACILITY NAME:
HEADWAY HOUSE, INC.
FACILITY NUMBER:
197604143
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
03/17/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(5)(A)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (A) There is written direction from a physician, on a prescription blank, specifying the name of the client, the name of the medication, all of the information specified in Section 80075(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication of when the physician should be contacted for a medication reevaluation.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review),the licensee did not comply with the section cited above. S2 has incomplete medications records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
03/25/2025
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Eva Miller
LICENSING EVALUATOR NAME:
Mariana Agban
LICENSING EVALUATOR SIGNATURE:
DATE:
03/17/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/17/2025
LIC809
(FAS) - (06/04)
Page:
8
of
8